Capita selecta clinical neuropsychology
CH1 – VISION
Theory
Vision – processing visual information from the environment and
interpreting it as conscious visual stimuli.
- Subcortical networks – from eye to posterior of the brain
- Cortical networks – linking different regions within the brain.
- Ocular system – collects light from the environment and converts
into chemico-electrical signals.
o Iris – regulates light intensity
o Lens and eye globe – refract or
bend light rays to focus on the
retina where the rods and cones
respond different to light of
different wavelengths.
o Visual info leaves the retina and
travels via the optic nerve, which
becomes the optic tract to the
lateral geniculate nucleus in the
thalamus and continues via optic
radiation and reaches visual striate cortex (V1).
- Pathways
o Magnocellular pathway – detects movement (location,
speed, direction)
o Parvocellular pathway – processes spatial resolution
(shape, color, size)
o Dorsal stream (where pathway) – motion
perception, spatial relationships
From visual cortex to posterior
parietal lobe
o Ventral stream (what pathway) – object
form and recognition.
From visual cortex to inferior
temporal lobe
o Magno and parvocellular pathways go from
subcortical to V1 (early pathways)
- V1 – visual striate cortex – for conscious processing of visual
stimuli.
Development of the visual system
- Rapid development in first year of life, continues during early
childhood.
- Sensitive periods of neuroplasticity (if eye deprived in this period,
may never develop normal vision.
- Visual acuity – level at which fine detail can be resolved.
o At birth very poor, around 7 years at adult level
Childhood vision impairment
- Almost all aspects of daily functioning rely on vision.
, - Peripheral visual system impairment – damage to eye globe,
retina or anterior optic nerve. (often congenital)
- Congenital cerebral visual impairment – due to damage to areas
of the brain involved in processing visual stimuli.
- Early development
o Reduced vision limits opportunities for social and
sensorimotor.
Object understanding develops more slowly.
Reach milestones later
- Higher risk of intellectual disability, but many achieve normal or
high intelligence.
- Difficulties with attention shifting and everyday executive
function.
- Verbal memory often normal or better than peers.
- Language and social communication
o Strong reliance on language for learning
o Higher autism rates
o Social interaction affected by limited eye contact and facial
cues.
- Lower adaptive skills, linked to quality of life
- Dorsal stream vulnerability – children with vision impairment
(and other disorders) have a cluster of visuocognitive deficits largely
located within the dorsal stream.
Assessment and formulation
Assessment principles
- Avoid tests with visual materials
- Focus on strengths and weaknesses
- Don’t assume all difficulties are due to vision, consider other
disorders.
Preparation
- Take detailed history + input from professionals.
o Also prior visual experience highly relevant
Acquired vs congenital vision impairment
- Consider level of vision
- Use usual learning methods.
Challenges
- Many tests rely on vision
- Questionnaires/autism assessment must be adapted.
- Few standardized tests for vision impairment
Intervention and management
- Early home-based, parent-mediated intervention > improves
cognition, language, behavior and enhanced parental support.
o Specialists provide the delivery
- Classroom support > reduce barriers (reduced opportunities for
multisensory learning) and manage attention difficulties (reduce
auditory distractors) and (acoustical) environment.
, - Support executive functioning using structured teaching and
verbal strategies.
o Verbal mediation strategies > promoting self-regulation.
- Technology and adaptations (braille tools, large screens) can support
learning.
Summary
- Children with visual impairment follow a distinct developmental
trajectory
- Standard assessment should be used with caution due to limited
validity.
- Best practice > information from multiple sources
- Key risk: underestimating potential
- Goal: optimize development, participation and quality of life through
tailored support.
CH2 – HEARING
Theory
Permanent sensorineural hearing loss is considered low-incidence.
- Genetic anomalies are primary cause (60%) the rest is syndromic.
- Delays in language development and cognitive, behavioral, social
and emotional domains.
Cochlear implants give access to speech sounds and enhance spoken
language and literacy development.
- Do not restore normal hearing
Auditory neural pathway – decodes sounds in terms of their
duration, intensity, frequency and location, followed by integration
with other sensory input and recognizes and processes in the context
of previously learnt information.
- Includes: hair cells of the cochlea, auditory nerve, brain stem,
thalamus, auditory cortex in temporal lobe.
- Congenital or prelingual sensorineural hearing loss (due to
damage or absence of hair cells) disrupts development of
auditory neural pathway at earliest stage.
o Results in reorganization of function of the central auditory
pathways.
- Connectome – a comprehensive map of neural connections in the
human brain.
o Links brain structure to function
o Helps understand how brain function is affected if structure is
disrupted.
o Absence of stimulation of auditory nervous system in early
life > prevents typical maturation > language, visual
processing, sequential processing, EF and concept formation.
- Types of hearing loss and associated difficulties
o Normal hearing – no difficulties
o Mild – difficulty following speech in noisy situations
o Moderate – difficulty following speech without hearing aid
o Severe – require powerful hearing aids or cochlear implant.
, o Profound – you rely on lip-reading/sign language or a
cochlear implant.
- General intellectual ability
o Generally, no difference between hearing or impaired
hearing (nonverbal tasks).
- Deficits or delays in:
o Attention (sustained visual attention), memory (short-term
and working), reasoning/problem-solving, and social
cognition.
Assessment and formulation
The goal of assessment depends on reason for referral:
1. Establish learning potential
2. Identify ability-achievement discrepancy (nonverbal ability)
3. Diagnose coincidental learning disability or disorder
4. Describe cognitive profile with hypotheses
Testing considerations for hearing impaired
- Limit background noise
- Sit opposite the child so they can lip-read if needed (in good lighting)
- Use frequency modulation system if child uses one.
- Be flexible > have different assessment tools available.
Intervention and management
General educational strategies
- First-line interventions
o Deaf awareness training for staff
o Seating child in front with view of the teacher
o Optimizing acoustics of classroom
- Increasing visual cues (pictures, diagrams, graphs)
- Providing written summaries and instructions rather than only
speaking them.
- Allowing extra processing time
- Avoiding multitasking
- Pre-teaching of new vocabulary topic/overlearning essential info.
- Checking comprehension
- Classroom interventions need to be tailored to the individual.
Intervention research
- Executive functions interventions (empirical evidence extremely
rare)
o Working memory intervention > benefits no longer evident
at 6 months.
o Useful focus for future research.
Summary
- Significant heterogeneity of hearing-impaired children.
- Understanding aetiology of child’s deafness important during
assessment.
- Consider purpose of assessment
- Gather info about child before meeting them
CH1 – VISION
Theory
Vision – processing visual information from the environment and
interpreting it as conscious visual stimuli.
- Subcortical networks – from eye to posterior of the brain
- Cortical networks – linking different regions within the brain.
- Ocular system – collects light from the environment and converts
into chemico-electrical signals.
o Iris – regulates light intensity
o Lens and eye globe – refract or
bend light rays to focus on the
retina where the rods and cones
respond different to light of
different wavelengths.
o Visual info leaves the retina and
travels via the optic nerve, which
becomes the optic tract to the
lateral geniculate nucleus in the
thalamus and continues via optic
radiation and reaches visual striate cortex (V1).
- Pathways
o Magnocellular pathway – detects movement (location,
speed, direction)
o Parvocellular pathway – processes spatial resolution
(shape, color, size)
o Dorsal stream (where pathway) – motion
perception, spatial relationships
From visual cortex to posterior
parietal lobe
o Ventral stream (what pathway) – object
form and recognition.
From visual cortex to inferior
temporal lobe
o Magno and parvocellular pathways go from
subcortical to V1 (early pathways)
- V1 – visual striate cortex – for conscious processing of visual
stimuli.
Development of the visual system
- Rapid development in first year of life, continues during early
childhood.
- Sensitive periods of neuroplasticity (if eye deprived in this period,
may never develop normal vision.
- Visual acuity – level at which fine detail can be resolved.
o At birth very poor, around 7 years at adult level
Childhood vision impairment
- Almost all aspects of daily functioning rely on vision.
, - Peripheral visual system impairment – damage to eye globe,
retina or anterior optic nerve. (often congenital)
- Congenital cerebral visual impairment – due to damage to areas
of the brain involved in processing visual stimuli.
- Early development
o Reduced vision limits opportunities for social and
sensorimotor.
Object understanding develops more slowly.
Reach milestones later
- Higher risk of intellectual disability, but many achieve normal or
high intelligence.
- Difficulties with attention shifting and everyday executive
function.
- Verbal memory often normal or better than peers.
- Language and social communication
o Strong reliance on language for learning
o Higher autism rates
o Social interaction affected by limited eye contact and facial
cues.
- Lower adaptive skills, linked to quality of life
- Dorsal stream vulnerability – children with vision impairment
(and other disorders) have a cluster of visuocognitive deficits largely
located within the dorsal stream.
Assessment and formulation
Assessment principles
- Avoid tests with visual materials
- Focus on strengths and weaknesses
- Don’t assume all difficulties are due to vision, consider other
disorders.
Preparation
- Take detailed history + input from professionals.
o Also prior visual experience highly relevant
Acquired vs congenital vision impairment
- Consider level of vision
- Use usual learning methods.
Challenges
- Many tests rely on vision
- Questionnaires/autism assessment must be adapted.
- Few standardized tests for vision impairment
Intervention and management
- Early home-based, parent-mediated intervention > improves
cognition, language, behavior and enhanced parental support.
o Specialists provide the delivery
- Classroom support > reduce barriers (reduced opportunities for
multisensory learning) and manage attention difficulties (reduce
auditory distractors) and (acoustical) environment.
, - Support executive functioning using structured teaching and
verbal strategies.
o Verbal mediation strategies > promoting self-regulation.
- Technology and adaptations (braille tools, large screens) can support
learning.
Summary
- Children with visual impairment follow a distinct developmental
trajectory
- Standard assessment should be used with caution due to limited
validity.
- Best practice > information from multiple sources
- Key risk: underestimating potential
- Goal: optimize development, participation and quality of life through
tailored support.
CH2 – HEARING
Theory
Permanent sensorineural hearing loss is considered low-incidence.
- Genetic anomalies are primary cause (60%) the rest is syndromic.
- Delays in language development and cognitive, behavioral, social
and emotional domains.
Cochlear implants give access to speech sounds and enhance spoken
language and literacy development.
- Do not restore normal hearing
Auditory neural pathway – decodes sounds in terms of their
duration, intensity, frequency and location, followed by integration
with other sensory input and recognizes and processes in the context
of previously learnt information.
- Includes: hair cells of the cochlea, auditory nerve, brain stem,
thalamus, auditory cortex in temporal lobe.
- Congenital or prelingual sensorineural hearing loss (due to
damage or absence of hair cells) disrupts development of
auditory neural pathway at earliest stage.
o Results in reorganization of function of the central auditory
pathways.
- Connectome – a comprehensive map of neural connections in the
human brain.
o Links brain structure to function
o Helps understand how brain function is affected if structure is
disrupted.
o Absence of stimulation of auditory nervous system in early
life > prevents typical maturation > language, visual
processing, sequential processing, EF and concept formation.
- Types of hearing loss and associated difficulties
o Normal hearing – no difficulties
o Mild – difficulty following speech in noisy situations
o Moderate – difficulty following speech without hearing aid
o Severe – require powerful hearing aids or cochlear implant.
, o Profound – you rely on lip-reading/sign language or a
cochlear implant.
- General intellectual ability
o Generally, no difference between hearing or impaired
hearing (nonverbal tasks).
- Deficits or delays in:
o Attention (sustained visual attention), memory (short-term
and working), reasoning/problem-solving, and social
cognition.
Assessment and formulation
The goal of assessment depends on reason for referral:
1. Establish learning potential
2. Identify ability-achievement discrepancy (nonverbal ability)
3. Diagnose coincidental learning disability or disorder
4. Describe cognitive profile with hypotheses
Testing considerations for hearing impaired
- Limit background noise
- Sit opposite the child so they can lip-read if needed (in good lighting)
- Use frequency modulation system if child uses one.
- Be flexible > have different assessment tools available.
Intervention and management
General educational strategies
- First-line interventions
o Deaf awareness training for staff
o Seating child in front with view of the teacher
o Optimizing acoustics of classroom
- Increasing visual cues (pictures, diagrams, graphs)
- Providing written summaries and instructions rather than only
speaking them.
- Allowing extra processing time
- Avoiding multitasking
- Pre-teaching of new vocabulary topic/overlearning essential info.
- Checking comprehension
- Classroom interventions need to be tailored to the individual.
Intervention research
- Executive functions interventions (empirical evidence extremely
rare)
o Working memory intervention > benefits no longer evident
at 6 months.
o Useful focus for future research.
Summary
- Significant heterogeneity of hearing-impaired children.
- Understanding aetiology of child’s deafness important during
assessment.
- Consider purpose of assessment
- Gather info about child before meeting them
